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BACKGROUND: Sensory nerve dysfunction in patients with hallux valgus has been described as both a symptom of the deformity and a complication of the treatment. The purpose of this study was to quantify nerve dysfunction in hallux valgus patients and to prospectively evaluate whether the trauma of surgery or the correction of the deformity had any effect on the sensory nerve function. METHODS: Fifty-seven consecutive feet undergoing operative correction for hallux valgus were prospectively enrolled. Preoperative and 3-, 6-, and 24-month postoperative clinical, radiographic, and detailed sensory examinations were completed. For the sensory examination, a Semmes-Weinstein 5.07 monofilament was used to establish, if present, a geometric area of sensory deficit about the hallux. This area was traced onto calibrated graphing paper and processed with imaging software. A total of 48/57 (84%) went on to complete 24 months of follow-up. RESULTS: Preoperative sensory area deficit improved by a mean of 529 mm2 at 24-month follow-up. The mean preoperative sensory deficit area was 688 mm2 (SD 681 mm2, range: 0 to 2885 mm2) and 24-month postoperative sensory deficit area was 159 mm2 (SD 329 mm2, range: 0 to 1463 mm2). No clinically significant correlation existed between deficit and clinical outcome measures. CONCLUSIONS: This study showed that preoperative sensory deficits exist, and can improve up to 24 months after operative correction of the hallux valgus deformity. This supports the concept that sensory deficit in hallux valgus is at least partially caused by a reversible injury to the sensory nerves, not necessarily a complication of surgery. LEVEL OF EVIDENCE: Level IV, case series.

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BACKGROUND: Patient dissatisfaction following surgical correction of hallux valgus remains a clinical problem. The aim of this study was to investigate articular erosion patterns of the first metatarsal head in patients with hallux valgus, to evaluate if the cartilage damage was associated with the degree of hallux valgus deformity, and to prospectively evaluate the effect on patient outcomes. METHODS: Fifty-six consecutive feet undergoing surgical correction for hallux valgus were prospectively enrolled and followed for 24 months postoperatively. In addition to clinical and radiographic examinations, intraoperative measurements were obtained to quantify osteochondral lesion location, size, and grade of the first metatarsal head cartilage. RESULTS: Fifty-one of 56 feet (91%) had osteochondral lesions. The mean number of zones affected was 2.9, and the mean maximum International Cartilage Repair Society (ICRS) scale lesion grade was 2.9 out of 4. A total of 44/56 (79%) completed a minimum of 24 months of follow-up. The grade of the lesion and the extent of the lesion did not have a strong correlation with the radiographic measures or clinical outcome scores. CONCLUSIONS: This study showed a high prevalence of osteochondral lesions in patients undergoing operative correction of hallux valgus. Since the grade and the extent of the lesions did not have a strong correlation with the severity of the deformity or the clinical outcome, the significance of these lesions remains unknown. LEVEL OF EVIDENCE: Level III, comparative series.

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BACKGROUND: Many techniques have been described for arthrodesis of the first metatarsophalangeal (MTP) joint. The purpose of this study was to determine the results of fixation using a low-profile dorsal titanium plate with locking screws in the phalanx, nonlocking screws in the metatarsal, and a plantar neutralization screw. METHODS: Forty-nine consecutive patients (51 feet) underwent a first MTP joint arthrodesis during an enrollment period of 1 year from October 2010 to November, 2011. All patients were evaluated preoperatively for primary pathology, pain, function, radiographic findings, AOFAS scores, and physical exam findings. First MTP joint arthrodesis was performed with a precontoured dorsal titanium plate with preset valgus and dorsiflexion after the joint surfaces were prepared with dome-shaped power reamers to achieve congruous cancellous bone surfaces. At a minimum of 1-year follow-up, patients returned for postoperative evaluation of pain, function, radiographic findings, satisfaction, AOFAS scores, and physical exam findings. RESULTS: Forty-six of 49 (48 feet) patients returned for final follow-up examination at least 12 months after operative intervention. Forty-one patients (89%) reported good to excellent results. Visual analog pain scores improved from an average of 6.6 preoperatively to an average of 1.6 postoperatively (t = -9.3339, df = 45, P < .001). Functional capacity scores improved from a preoperative mean of 2.5 to a postoperative mean of 1.4 (t = -5.2648, df = 46, P < .001). AOFAS hallux MTP joint scores improved from a preoperative mean of 45 to a postoperative mean of 77 (t = 9.9498, df = 46, P < .003). Eighteen of 48 great toes (38%) had preoperative pronation whereas, 2 of 48 great toes (4%) had postoperative pronation. Eleven of 46 patients (24%) were unable to perform preoperative toe rise, and 8 of 46 (17%) were unable to perform postoperative toe rise. Twenty-five of 46 patients (54%) had gait improvement, while 19 patients (44%) had no change in gait, and 2 patients (4%) had gait deterioration. The mean preoperative hallux valgus angle of 27 degrees improved to a mean postoperative angle of 13 degrees (t = -6.1982, df = 46, P < .001). The mean preoperative 1-2 intermetatarsal angle of 12 degrees improved to a mean postoperative angle of 9 degrees (t = -5.2614, df = 46, P < .001). There was 1 delayed union (2%) and 1 nonunion (2%). CONCLUSION: Our outcome scores indicate that first MTP joint arthrodesis with a precontoured dorsal titanium plate with locking screws in the phalanx and nonlocking screws in the first metatarsal is both reliable and reproducible with a very high bony union rate. LEVEL OF EVIDENCE: Level IV, prospective case series.

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The use of artificial turf in the United States has created a dramatic increase in first metatarsophalangeal joint dorsiflexion injuries. Turf toe has been reported to occur in athletes who participate in sporting activities. An injury to the plantar capsular ligamentous complex can result in acute and chronic pain, resulting in time lost from sports participation for a short- or long-term period. Classification of this injury is based on clinical findings and imaging studies, including plain radiographs and magnetic resonance imaging. The early recognition of this injury is crucial to successful treatment. Nonoperative treatment may often suffice for incomplete injuries; however, surgery may be warranted for a complete plantar plate disruption or injury to one or both sesamoids. In the high-performance or elite athlete, a turf toe or severe dorsiflexion injury can be disabling, and can threaten an athlete's career if not treated properly.

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BACKGROUND: A variety of treatment options exist for open pilon fractures of the distal end of the tibia. In this study, we evaluated the use of a staged protocol designed to minimize the risk of soft-tissue complications and to allow for optimal reduction of the fracture. METHODS: Sixty-eight patients presenting with an open pilon fracture were identified from a prospectively maintained database of 186 consecutive patients. Fifty-nine of the sixty-eight patients, with an average age of forty-seven years, were followed for an average of thirty-four months and formed the study cohort. Within this group, there were two grade-I, three grade-II, thirty-seven grade-IIIA, and seventeen grade-IIIB open injuries. Clinical and radiographic outcomes were assessed by individuals not involved in the treatment of the patients. Functional outcome was assessed, with use of the modified Mazur scoring system and Short Form-36 Version 2.0 questionnaire, for thirty-eight patients who were followed for a minimum of two years. RESULTS: Fifty-two of the fifty-nine fractures healed. Six fractures had bone-grafting, and each progressed uneventfully to union. One patient required an amputation following a failed free tissue transfer. Two patients (3%) were deemed to have a deep wound infection and were successfully treated with a six-week course of culture-specific intravenous antibiotics. Three patients (5%) had a superficial wound infection that was successfully treated with oral antibiotics. The average physical component score on the Short Form-36 Version 2.0 was 40.3 points. The average mental component score (54.9 points) was better than the age-matched norm in the majority of the age groups. The average modified Mazur score was 44.8 of a possible 100, with most patients scoring in the poor range. CONCLUSIONS: Open reduction and internal fixation of open pilon fractures was accomplished with an acceptable outcome and a low prevalence of soft-tissue complications. We believe these results can be reproduced through routine use of an individualized treatment algorithm including the use of staged procedures, meticulous soft-tissue management, liberal use of temporizing external fixation, and a patient-specific approach to fixation and soft-tissue coverage.

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